Ruminations by a non-academic general surgeon from the heart of the rust belt.

Wednesday, March 17, 2010

I'm Sold

Health care reform needs to pass. I'm sorry. It just has to. This transcends politics and ideology and all the other b.s we have to listen to on FoxNews and CNN. It's become one of the defining moral issues of our time (along with the torture scandal, of course.) This article from the NY Times puts things in perspective: Study Finds 1 in 4 Uninsured in California. And I wanted to highlight a full quote from one of the commenters in the article.

I have been working as a freelance marketing writer in Silicon Valley for the past ten years and am now age 62. The premiums for somebody my age, though I am in good health (so far) would be wallopingly high --- if I could even get insurance. However, nobody will touch me because of my age, even at ruinous rates. My income is up-and-down in this economy; when business is good, I am able to pay as I go for basic exams and preventive care and the odd case of the flu. But other times I have had to borrow on my car's pink slip to pay medical bills and even my rent (a brutal 99 percent rate of interest!) And my good health could change in the blink of an eye, of course. Pretty scary.

I am not able to get full time work with benefits despite my efforts. Companies know that they have people like me over a barrel, so they hire us as 1099s with no benefits, and we grab every bit of work we can get, you may be sure.

I recall my health insurance premiums back in the early 2000s were only $250 a month through Blue Shield. I could always scrape that together. But I am uninsured now. I have deep experience and an education from a top university, but I have no security at all. I plan to keep working until I drop in my traces. Am I not worth basic medical insurance?

The story is heartbreaking. How is it that we've determined that the provision of basic health care to our citizens is just another commodity, availability to be determined by market forces and "principles of free enterprise"? Socialism you say? Government takeover? What about those highways you take to work? Or the museums and public parks you visit to refresh your soul? Or the elementary school you send your kids to around the corner? Or the police and fire departments that we depend on in communities across the land? Or the little social security check your elderly parents receive? How thankful are you that granny has Medicare? These are all publicly funded programs, people. They represent the unacknowledged "socialistic" impulse that pervades our nation's moral soul. A long time ago we decided that no child should be without an opportunity to receive a basic education. It was such an obvious ethical conclusion that there has never been much opposition to the idea of using public funds to provide for the schooling of its youth. Granted, there are inefficiencies and injustices. We have a tiered system. Urban, inner city schools are poorly funded and ambivalently managed. But at least a kid growing up in inner city Chicago has a school to go to!

How is it that we have collectively excluded the provision of health care to its working citizens and children from the category of public goods that are justifiably paid for by public funds? Why are we ok with pooling our resources to pave our roads every two years but if you propose to disconnect the ridiculous, anachronistic symbiosis between health care and employment, you're called a communistic nazi? It just makes no sense.

The reform bill pending right now is about as watered down a version of reform as you will ever see. There is no public option. The private health insurers are happy. Big Pharm has been paid off. Doctors are going to get screwed. But anything bolder or more egalitarian would stand no chance. The FoxNews/GOP noise machine has already won the PR battle. Obama is a socialist. Goverment takeover. He's going to steal your Medicare. Ultimately, the bill won't be good enough (doesn't include all 47 million uninsured, too many concessions to corporate America, too much faith in cost control prognostications), but at least it represents a step in the right direction. I know, that sounds passive and patronizing----at least it's something, blah blah blah. But we have to stop averting our eyes from unpleasant facts. The time to intervene is now. If it fails, no one will touch health care reform for another generation....

13 comments:

I don't get it, No Pubic Option, Payoffs to Big Insurance/Pharm that would make Bernie Madeoffs mouth water, Doctors takin it up the rear like Barney Frank in his prime, and it's a step in the right direction???Thats what they said at Treblinka, its just "De-Lousing!!!' its "Free!!!" who wants to get Typhus???!!!No one will touch health reform for a generation??? Thats a good thing.And you know that Doctor Fix is only until the end of the Month???

I agree, Buckeye, the bill is imperfect but is as good as we can expect. The larger issue is that we need to reform the political system first. Only after you remove the massive amounts of lobbyist money from the system, and have an electorate that is not so easily influenced by propaganda from the media, can you achieve real reform in this country (on any issue).And 3 cheers for NO TORT REFORM!

I know people with only catastrophic insurance who will not get exams for themselves for fear of dx preventing them from even the catastrophic temporary insurance renewal and bankruptcy. They are professionals with families, out of work who cannot afford COBRA/mortgage/kids. They are not crazy, I'd do the same thing.

Without any changes, you all (me included) are gonna be out of work sooner or later. People just can't pay the bills. But hey, I know that if I got into trouble and needed emergent surgery, I could call you Buckeye, and you Frank and we could use my kitchen table. Oh, and Frank, I have a TV in the kitchen :o)

I understand the idealist who wants healthcare for all and thinks it should be a civil right but there's never a free lunch. Do people really believe the GDP numbers that the CBO projects along with the associated tax revenues? Our country has expanded mostly due to credit over the last 20 years. The Japanese economy in 1990 suffered from many of the same symptoms that we are suffering from. In Japan today stocks and real estate prices are on average 25% of what they were in 1990. From 1990 to 2000 Japan had huge budget deficits due to infrastructure spending and still no recovery. Given the track record of our government, I wouldn't be optimistic. Obama would think the healthcare bill is a "good start". I agree with him that it's a “good start” to much higher taxes and more government waste.

HOWEVER, the only way we are going to seriously cut costs in this country is with rational rationing. That is how europe and canada do it. It doesn't take a rocket scientist to figure it out. You will not get dialysis or a CABG in your 80's. You will not third line chemo at 50 K per month. Actually the europeans don't even allow our outlandish prices for drugs. Guess what, pharma still plays with europe. Until this is done we are all just standing around pissing in the wind. That includes americans who think they can get everything now for everybody or they will sue.

House Democrats voted 219-212 late Sunday to send the landmark legislation to Obama. The 10-year, $938 billion bill would extend coverage to 32 million uninsured Americans, reduce deficits and ban insurance company practices such as charging more to women and denying coverage to people with pre-existing medical conditions.Obama is expected to sign the bill Tuesday at the White House, spokesman Robert Gibbs said Monday.

Buckeye, I'm surprised at this post. After all, not too long ago, you had a well-timed post against your being taxed at an unreasonable rate (see "Welcome to the Real World"). Why the change of heart? An additional tax on those making $200,000 and more, reduced Medicare reimbursements, new, expanded Medicaid obligations in state budgets, a 40% tax on existing "good" medical plans, new excise taxes on tanning salons, pharmaceutical companies, device manufacturers, and health insurers (ultimately passed on to the end users). Buckeye, if any significant amount of your business is Medicare, your reimbursements are going down while your taxes go up.

This bill proposes a shotgun fix in the wake of a majority in both houses of Congress and the midterm elections. This is not a problem that can be solved by this bill. The American Academy of Family Physicians predicts a 40,000 shortage of their own pedigree by 2020. Let's consider the numbers further: it takes at least 7 years to train a physician. Our current physicians are expected to take on 32 million new customers by 2014. Nurse practitioners and PAs are looking to fill this gap in care, making doctors in primary care less relevant. In fact, nurse practitioner programs are transitioning to offering only doctoral programs to "be on the same parity of respect with doctors." Nurse anesthetists on average now earn more than the average family practitioner.

The mandate for insurance has few teeth. For an individual, a $95 penalty in 2014 increasing to $695 by 2016. Is there a health plan that costs $695 a year? Guaranteed issue of health insurance only works with enough payees, and this penalty is not exactly an incentive to purchase a policy.

The solutions are not pretty, but when taken in small doses, like sips of alkaselzer, you have measurable progress. First, fund more residency positions in primary care to take on the additional patients. Then implement guaranteed issue of health insurance with a stronger purchase mandate. Leave the feds out of modifying health premiums, otherwise every federal official will run on lower health premiums without regard to solvency. Allow states to recover if adopting the unfunded mandate of expanded Medicaid eligibility and greater reimbursements. Oh, and what about tort reform?

The California Medical Association claims that 70% of CA physicians do not see Medicaid patients.

So what does all this mean to me? Insurance does not equal access-MediCaid for all is not solution-Think money for gas, but no gas station.

We need a plan that supports appropriate geographic distribution of primary and specialty care-this will likely mean "employed physicians" to insulate them from the economic reality of taking care of the poor and marginally insured.

Perhaps we should be discussing the issue in the context of Public Health

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